Kidney Week

Abstract: PUB544

Management of Primary Membranous Nephropathy (PMN) after Transplant

Session Information

• Publication Only

Category: Transplantation

• 2102 Transplantation: Clinical

Authors

• Abu Al Rub, Fadee, Saint Louis University, St Louis, Missouri, United States

Fadee Abu Al Rub, MD

• Shaikh, Sana J., University of California Davis, Davis, California, United States

Sana J. Shaikh, MD

• Lentine, Krista L., Saint Louis University, St Louis, Missouri, United States

Krista L. Lentine, MD, PhD, FASN

Introduction

PLA2R Ab were identified as the underlying cause in about 70% of PMN cases. After transplant (TXP), PMN recurrence rate is about 31%. A more aggressive disease and a higher level of PLA2R Ab in native kidneys can predict recurrence.

Case Description

We reviewed records of 6 kidney TXP patients with biopsy (Bx) proven MN, 3 of them had negative PLA2R Ab at the time of surgery, and had no complications. We followed the other three for one-year and here we report their course:
All patients received Thymo for induction, and their maintenance regimen consisted of: Tacrolimus, MMF +/- and prednisone.
One patient had a 3-month protocol biopsy which showed PLA2R-positive MN despite intact renal function and negative serum PLA2R titers. He received Rituximab (RX) 1 gm x 2 doses 14 days apart.
Another patient had a cause biopsy for elevated cell free DNA at the end of the first month, and it showed MN recurrence. He had high PLA2R titers and mild proteinuria. He was treated with RX as above.
The third patient had a protocol biopsy which was negative, and no alteration in immunosuppression needed to be made.

Discussion

Since It was observed that patients with positive anti-PLA2R Ab testing before TXP, who continued to have high titers despite induction and maintenance immunosuppression, were likely to develop an early recurrence of MN. It is reasonable to consider pre-emptive Rituximab: First, at the time of TXP in those with high titers of anti-PLA2R Ab, and in the first month post-transplant if the titers of anti-PLA2R ab remain elevated.
We also suggest treating a living donor recipient candidate before surgery, if his PLA2R level is elevated, to avoid recurrence.
It is noted here too that cell-free DNA technology was helpful in detecting MN recurrence, as it triggered the biopsy decision. More studies are needed to evaluate its sensitivity in screening for glomerulonephritis recurrence in an allograft.